Provider Demographics
NPI:1265474621
Name:ROOT, SPENCER SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:SPENCER
Middle Name:SCOTT
Last Name:ROOT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2512 WHEATON WAY
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98310-3399
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2200 NW MYHRE RD
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-7681
Practice Address - Country:US
Practice Address - Phone:360-830-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00037962207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8250938Medicaid
WA131361OtherLABOR & INDUSTRIES
7254073OtherAETNA
7037ROOtherREGENCE BLUESHIELD
7037ROOtherREGENCE BLUESHIELD
BR6668175OtherDEA
7037ROOtherREGENCE BLUESHIELD
WA131361OtherLABOR & INDUSTRIES
WAGAB12659Medicare PIN
WAG8851965Medicare PIN
WAGAB12663Medicare PIN
WAGAB12662Medicare PIN
WAGAB05199Medicare PIN